Prime Therapeutics Pharmacy Claims Auditor in Richmond, Virginia
Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make.
Job Posting Title
Pharmacy Claims Auditor
The Pharmacy Claims Auditor is responsible for the selection and auditing of claims, educating Prime’s network pharmacies and driving contract compliance, and supporting downstream claim corrections and eliminate potential waste.
Validate claim documentation and systems data to ensure claim was accurately processed in accordance with contractual and regulatory obligations
Solicit documentation to support pharmacy claim submission by conducting telephonic, fax or email outreach to pharmacies
Proactively communicate and follow up with pharmacies to drive timely and accurate documentation receipt and review
Analyze pharmacy claims to identify those at the highest risk for error; utilize analytics and professional knowledge to select claims or pharmacies for audit in alignment with department procedures and objectives Educate participating pharmacies on Prime’s billing requirements and appropriate billing practices in alignment with Prime Therapeutics’ Pharmacy Provider Manual
Based on audit outcome, work directly with pharmacy or internal partners to support accurate data and financial reimbursement to ensure appropriate reversal or correction of claim is performed
Other duties as assigned
Bachelor’s degree in Health Science or related area of study, or equivalent combination of education and related work experience; HS diploma or GED required
National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)
2 years of work experience in retail, long term care, specialty, home infusion, or mail order pharmacy or combined pharmacy and Pharmacy Benefit Management experience to include 1 year of work experience in an operations, audit or quality assurance environment
Must be eligible to work in the United States without need for work visa or residency sponsorship
Proficiency in MS Word, Excel, and database software
Intermediate skill and understanding of the point of sale and on-line pharmacy claims processing environment
Excellent oral, written and interpersonal communication skills
Self-directed worker with excellent organization and analytical skills
Ability to work effectively with a variety of audiences at all levels of the organization
Ability to maintain confidentiality of highly sensitive information
Professional appearance, demeanor, and conflict resolution skills
3 years of previous audit experience
Current Registration with State Board of Pharmacy in the state where position is located
Previous PBM experience
Minimum Physical Job Requirements
Ability to work a flexible schedule including weekends, holidays, or shifts outside of Prime’s core business hours of 9:00am-4:00pm
Frequently required to sit, use hands to handle or feel, talk and hear
Frequently required to stand, use hands to handle or feel, talk and hear
Frequently required to reach with hands and arms
Occasionally required to stand, walk and stoop, kneel, and crouch
Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds
Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus
- Reports to a Manager in the Pharmacy Audit and FWA department
Potential pay for this position ranges from $48,700.00 - $72,700.00 based on location, experience and skills.
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page (https://www.primetherapeutics.com/en/careers/benefits.html) and click on the "Benefits at a glance" button for more detail.
Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.